Payer Accountability & Negotiation

Use cases emphasizing holding payers accountable, improving contract compliance, and leveraging data for better payer negotiations.

Leveraging Data Analytics for Contract Negotiation and Accountability

Two independent practices needed stronger evidence to negotiate higher contracted rates with their top payers. Sampling claims through a consulting firm was not enough to show the scale of underpayments. They also lacked a reliable way to confirm whether payers were meeting new contracted rates after negotiations.

  • RevOps analyzed the entire claims and remittance dataset, revealing inconsistent reimbursements at the payer, code, and service level. After renegotiation, automated watchers monitored high value codes daily, flagging any allowed amounts that fell below contracted rates. Leadership received weekly reports quantifying underpayment impact.

    • Secured higher contracted rates with comprehensive evidence of payer underpayments

    • Ensured compliance with new contracts using automated monitoring and weekly audit reports

    • Recovered missed revenue by identifying rate discrepancies early and holding payers accountable

Uncovering Hidden Underpayments in COVID-19 Testing Claims

An urgent care network expected around $280,000 in COVID testing revenue, but actual payments fell far short. Their EHR analytics showed a 100 percent payment rate, masking the fact that the payer split the claim into two parts and denied the clinic fee 39 percent of the time. Nearly 30 percent of expected revenue went uncollected.

  • RevOps isolated the pattern of partial payments, quantified an $85,260 shortfall, and exported all affected claims for resubmission. Watchers were deployed to detect similar issues going forward, alerting staff any time a test was paid incorrectly so the issue could be addressed before revenue was lost.

    • Recovered $85,260 in missed revenue caused by hidden partial denials

    • Prevented future loss by monitoring clinic fee denials in real time

    • Gained full transparency into payer behavior that EHR reporting failed to detect

Identifying and Addressing Preauthorization Denials

A large health system saw a surge of UBH denials tied to a mismatch between preauthorized services and claim details. Their existing tools only allowed account level review, making it impossible to detect patterns across claims. Denials reached 60 percent of total volume, creating major financial strain.

  • RevOps revealed an unusual spike in N54 preauthorization mismatch codes using RARC distribution graphs and drill down tools. The team engaged clinicians, billers, and payer portal developers to correct authorization logic. Watchers were deployed to monitor N54 activity and alert staff to any recurrence.

    • Recovered $1.5M in denied claims by resolving authorization mismatch issues

    • Eliminated most N54 denials by aligning payer portal logic with clinical workflows

    • Strengthened cross departmental coordination with clear visibility into root causes

Verifying Regional Variations in Reprocessing Performance

A mental health system relied on Aetna’s automated bot to reprocess incorrect residential treatment claims. While other states saw corrected payments, one state continued to experience high denial rates. Existing tools could not compare performance across regions or validate payer side errors.

  • RevOps quantified a $500,000 reprocessing shortfall by comparing expected versus actual outcomes region by region. The platform validated the payer discrepancy with clear evidence and helped the organization present a localized, data backed case to Aetna for correction.

    • Identified a $500,000 gap caused by failed payer reprocessing in a single state

    • Pressured the payer to correct bot logic with precise, region specific evidence

    • Established a repeatable audit process to monitor reprocessing accuracy going forward

Ensuring Transparency and Accountability in Offshored RCM Operations

A multi state healthcare organization offshored part of its RCM workflow to reduce labor costs. But leadership lacked transparency into the offshore team’s performance. Traditional reports provided only high level outcomes, leaving revenue integrity, claim timeliness, and denial trends unclear.

  • RevOps provided granular metrics across days to payment, denial patterns, CARC codes, and regional benchmarks. Leaders could compare offshore performance to internally managed regions, quantify financial impact, and intervene quickly if delays or errors surfaced.

    • Restored full visibility into offshore RCM operations with detailed performance metrics

    • Ensured cost savings did not hide revenue leakage or increased denial rates

    • Strengthened vendor accountability through transparent comparisons with internal teams

Resolving Complex Underpayments Through Contract Oversight

A behavioral health system discovered that eating disorder claims were consistently reimbursed at lower mental health rates, causing hundreds of thousands in underpayments. Additional errors occurred each year during payer system updates, resulting in outdated contracted rates being applied for months.

  • RevOps identified misapplied rates using treatment level analysis, quantified the shortfall at over $1M, and armed the organization with evidence to demand corrections. The team established an annual audit protocol to ensure proper rate updates across regions.

    • Recovered more than $1M in underpayments tied to misapplied reimbursement rates

    • Fixed recurring annual issues by implementing a structured contract audit process

    • Improved payer compliance and reduced future discrepancies with data backed oversight

Challenging a $1.3M Value Based Care Penalty

A statewide OB practice received a $1.3M downside risk penalty from Anthem but had no way to validate the payer’s cost calculations. Anthem provided only summary data, assuming the practice lacked the tools to challenge it. Traditional systems could not model VBC cost attribution or apply required exclusions.

  • RevOps extracted all OB and hysterectomy episodes, structured the payer data, applied exclusions, and modeled costs using LLM assisted financial formulas. The practice benchmarked expenses against medical inflation and isolated facility driven costs outside their control. They re engaged Anthem with precise, verifiable evidence.

    • Countered a $1.3M penalty with detailed evidence, reducing liability to $300K or less

    • Replaced opaque payer assertions with transparent, structured financial analysis

    • Built a repeatable framework for monitoring VBC performance across future contracts

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